Keywords
neurotrauma audit - head injury - morbidity - mortality - neurotrauma - spine injury
Introduction
Traumatic brain injury and spine trauma are usually devastating injuries with significantly
high morbidity and mortality.[1] They constitute a significant proportion of global trauma burden and their incidence
is expected to increase with time due to the increasing population and use of motor
vehicles.[2] Middle-aged males are involved most commonly, adding to the magnitude of socioeconomic
burden.[3]
[4] As road traffic accident (RTA) is the most common cause, developing countries are
more affected due to poor infrastructure and noncompliance with traffic rules. The
outcomes are also worse in developing and poor countries due to limited resources
and financial constraints. For the prevention and better management of these patients,
it is mandatory to understand the demographic and clinical profile of cases of a particular
region. A few studies have been published from India describing the neurotrauma epidemiology
and outcomes; however, there are no studies from central India.
This study was aimed to describe the epidemiology, pattern, and outcomes of head injury
and spine injury patients at a tertiary care center in central India, which may prove
helpful in improving the ultimate outcome of these patients through better research
and strategy-making for prevention as well as treatment.
Materials and Methods
All the patients of head injury and spine injury admitted to the Department of Neurosurgery
between September 1, 2018, and August 31, 2019, were included in the study. Data of
all these patients were collected from the medical record section and analyzed for
age, sex, mode of injury, severity of injury, management, and outcomes.
Results
During the study period, 932 patients with head injury and 241 patients with spine
injury were admitted to our department. Around 65% of the patients in both head and
spine injury categories fell in the age group of 26 to 55 years ([Table 1]). Approximately 80% of all neurotrauma patients were male ([Table 2]). The most common mode of injury was RTA followed by fall from height ([Table 3]).
Table 1
Age distribution in head and spine injury cases
|
Age (years)
|
Head injury (n = 932)
|
Spine injury (n = 241)
|
|
< 10
|
41 (4.4%)
|
05 (2%)
|
|
10–25
|
98 (10.5%)
|
27 (11.2%)
|
|
26–40
|
306 (32.8%)
|
72 (29.9%)
|
|
41–55
|
316 (33.9%)
|
74 (30.7%)
|
|
56–70
|
152 (16.3%)
|
55 (22.8%)
|
|
> 70
|
19 (2%)
|
08 (3.3%)
|
Table 2
Sex distribution in head and spine injury cases
|
Sex
|
Head injury (n = 932)
|
Spine injury (n = 241)
|
|
Male
|
727 (78%)
|
192 (79.6%)
|
|
Female
|
205 (22%)
|
49 (20.3%)
|
Table 3
Mode of injury and alcohol influence in neurotrauma
|
Mode of Injury
|
Head injury (n = 932)
|
Spine injury (n = 241)
|
|
Road traffic accident
|
Total = 690 (74%)
|
Total = 166 (68.8%)
|
|
Motorcycle rider
|
370 (39.7%)
|
76 (31.5%)
|
|
Four-wheeler driver
|
134 (14.4%)
|
42 (17.4%)
|
|
Four-wheeler passenger
|
54 (5.7%)
|
20 (8.2%)
|
|
Pedestrians
|
109 (11.7%)
|
15 (6.2%)
|
|
Train
|
23 (2.5%)
|
13 (5.3%)
|
|
Fall from height
|
149 (15.9%)
|
47 (19.5%)
|
|
Assault
|
Total = 70 (7.5%)
|
Total = 13 (5.3%)
|
|
Blunt
|
38 (4%)
|
08 (3.3%)
|
|
Sharp
|
25 (2.6%)
|
04 (1.6%)
|
|
Gunshot
|
07 (0.7%)
|
01 (0.4%)
|
|
Heavy object fall
|
15 (1.6%)
|
12 (4.9%)
|
|
Miscellaneous (animal attack, blast injury, electrocution, etc.)
|
06 (0.6%)
|
02 (0.8%)
|
|
Unknown
|
04 (0.4%)
|
01 (0.4%)
|
|
Alcohol influence
|
248 (26.6%)
|
44 (18.2%)
|
Among the head injury patients, around 47% were managed surgically ([Fig. 1]). Mean hospital stay for minor, moderate, and severe head injury cases was 7.4,
14.9, and 22.7 days, respectively ([Fig. 2]). Mean mortality for minor, moderate, and severe head injury cases was 2.3, 13.3,
and 39%, respectively ([Fig. 3]). In the spine injury group, 37% were managed surgically ([Table 4]). Mean hospital stay varied with the ASIA (American Spinal Injury Association) grade
([Table 5]). Mortality for ASIA grades A and B for cervical spine injury was 66.6 and 53.8%,
respectively ([Table 6]).
Fig. 1 Surgical versus conservative management for head injury patients.
Fig. 2 Hospital stay for head injury patients. HI, head injury.
Fig. 3 Mortality in minor, moderate, and severe head injury patients. HI, head injury.
Table 4
Surgical versus conservative management of spine injury patients
|
Operated
|
Conservative
|
Total
|
|
Cervical spine injury
|
52
|
81
|
133
|
|
Dorsolumbar spine injury
|
38
|
70
|
108
|
Table 5
Hospital stay for spine injury
|
Level
|
ASIA grade
|
Minimum stay
|
Maximum stay
|
Mean stay
|
|
Abbreviations: ASIA, American Spinal Injury Association; DL, dorsolumbar.
|
|
Cervical spine
|
A
|
5
|
56
|
28.9
|
|
B
|
9
|
52
|
27.2
|
|
C
|
8
|
42
|
21.6
|
|
D
|
6
|
28
|
15.6
|
|
E
|
2
|
5
|
2.9
|
|
DL spine
|
A
|
8
|
22
|
15.6
|
|
B
|
9
|
20
|
14.9
|
|
C
|
8
|
19
|
15.2
|
|
D
|
9
|
19
|
14.7
|
|
E
|
2
|
8
|
2.8
|
Table 6
Mortality in spine injury
|
Level
|
ASIA grade
|
Total
|
Mortality
|
Percentage
|
|
Abbreviations: ASIA, American Spinal Injury Association; DL, dorsolumbar.
|
|
Cervical spine
|
A
|
42
|
28
|
66.6
|
|
B
|
39
|
21
|
53.8
|
|
C
|
22
|
2
|
9
|
|
D
|
10
|
0
|
0
|
|
E
|
20
|
0
|
0
|
|
DL spine
|
A
|
53
|
09
|
16.9
|
|
B
|
33
|
02
|
6
|
|
C
|
04
|
01
|
25
|
|
D
|
07
|
00
|
0
|
|
E
|
11
|
00
|
0
|
Discussion
Department of Neurosurgery, NSCB Medical College, Jabalpur
Neurosurgery in Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh,
India, was started in 1992 under the Department of General Surgery, when Dr. Y. R.
Yadav joined as an assistant professor and later on established a separate Department
of Neurosurgery in 2012. Since then, this department is providing services to patients
of Mahakaushal region. At present, the department has eight faculty members (two professors,
two associate professors, and four assistant professors), two neuroendoscopy fellows,
and MCh residents, and is well known nationally and internationally in the field of
neurotrauma, microneurosurgery, and neuroendoscopy.
The department has more than 200 research publications in national and international
journals. The department has developed innovations in the field of neurosurgery. Tubular
retractor, made of silicone, is used in brain tumor surgeries and intracranial hematoma
surgeries. Custom-made inexpensive indigenous models for neuroendoscopy training have
also been developed by the department. Various novel neurosurgical techniques, especially
in the field of neuroendoscopy, have been developed by the department, which were
also published in reputed journals.
The department is running a neuroendoscopy certificate course of 11-month duration,
which is affiliated to the Madhya Pradesh Medical Science University. This is the
first fellowship course of neuroendoscopy in India. Superspecialty course (MCh) in
neurosurgery has also been started from the academic session 2019 to 2020. Apart from
this, the department conducts Neuroendoscopy Fellowship program and Oration twice
a year beginning from 2010 and has trained around 600 neurosurgeons from all over
India and 50 neurosurgeons from abroad in neuroendoscopy. Fellowship program comprises
3 days of live surgery including almost a complete spectrum of cranial and spinal
endoscopy surgeries followed by 2 days of hands-on cadaveric workshop under supervision.
Neurotrauma Audit
In this study that was performed at a tertiary care center of central India, head
and spine injury patients were retrospectively analyzed for the demographic profile,
mode, and pattern of injury, severity of injury, duration of hospital stay, and outcomes.
Majority of the head and spine injury patients (around two-thirds) in our study were
middle-aged earning members of the family, which is similar to other studies.[1]
[3] Less than 5% of patients were under 10 years of age. Males were four times more
commonly involved in injuries compared with females.[1]
[5] The most common mode of injury was RTA, and around 50% of the patients were motorcycle
riders. Fall from height was the second most common mode of injury. Mode of injury
was found to be similar to those reported in other studies found in the literature.[1]
[3]
[6] Few cases of trauma due to animal attack were also encountered in regions with dense
forest areas in the vicinity. Around 25 and 18% of head and spine injury patients,
respectively, were under alcohol influence at the time of injury, suggesting a need
for strict implications of traffic rules as well as awareness in general population.
Approximately half and one-third of head and spine injury patients, respectively,
were managed surgically. Spine injury patients with ASIA grade A were managed conservatively
most of the times in view of the poor expected outcome and limited facilities and
resources at our center. Mean hospital stay was 7.4, 14.9, and 22.7 days for minor,
moderate, and severe head injury patients, respectively. Mean stay for ASIA grade
A cervical spine injury patients was around 30 days, whereas that for ASIA grade A
dorsolumbar spine injury patients was 15 days on average. The higher mean stay for
cervical spine injury patients was because of respiratory involvement, need of ventilatory
support, and related complications. In consistency with the literature, mortality
for severe head injury patients was around 40%. Similarly, mortality for ASIA grades
A and B cervical spine injury patients was above 50%.
Conclusion
In this study, middle-aged males are found to be the most common sufferers of brain
and spine injury, with RTA being the most common mode of injury. Around one-fourth
of the patients were under alcohol influence. Even after aggressive treatment strategies,
morbidity and mortality are very high, and the ultimate outcome depends mainly on
the clinical status immediately after trauma. The data from this study can be helpful
in strategy-making for the prevention and management of head and spine injury patients,
especially in the central Indian population.
